Clinical use of uncovered balloon-expandable metallic biliary stents for treatment of extrahepatic biliary tract obstructions in cats and dogs: 11 cases (2012-2022)

OBJECTIVE

To describe the application of uncovered balloon-expandable metallic biliary stents for treatment of extrahepatic biliary obstructions (EHBOs) and the outcomes for dogs and cats treated for EHBO with this technique.

STUDY DESIGN

Retrospective single institutional study.

ANIMALS

Eight dogs and three cats treated at the Veterinary Specialty Hospital of San Diego for EHBO between January 2012 and February 2022.

METHODS

Data collected from the medical records included signalment, presenting complaint, laboratory and imaging findings, surgical findings, hospitalization time, complications, and follow-up information.

RESULTS

Median duration of short-term follow up was 16 days (6-45 days). Improved biochemical abnormalities and resolution of clinical signs were recorded in 10/11 cases. Two dogs died within 2 weeks of surgery. One dog developed systemic inflammatory response syndrome 5 days postoperatively and was euthanized; the cause of death in the second case was unknown. Long-term follow up was available in seven cases, with a median duration of 307.5 days (62-2268 days). Bile-duct patency was maintained for at least 356-622 days (median: 446 days) in three cats and 62-2268 days (median: 650.5 days) in four dogs with long-term follow up available. One cat had recurrent obstruction with choledocholiths 446 days postoperatively. One stent was removed 614 days postoperatively due to recurrent cholangiohepatitis.

CONCLUSION

Uncovered balloon-expandable metallic biliary stents were placed successfully and relieved EHBO in all cases that survived to discharge.

CLINICAL SIGNIFICANCE

Use of uncovered balloon-expandable metallic biliary stents should be considered as an alternative to temporary choledochal luminal stenting or cholecystoenterostomy to manage EHBO.

Features, management, and long-term outcome in dogs with pancreatitis and bile duct obstruction treated medically and surgically: 41 dogs (2015-2021)

OBJECTIVE

Pancreatitis resulting in extrahepatic biliary obstruction (EHBO) can cause substantial morbidity and mortality. Endoscopic retrograde cholangiopancreatography is utilized for diagnostic and therapeutic purposes in humans; however, this is not available in veterinary medicine. Treatment options include medical management and biliary drainage procedures. The aim of this study was to describe the management of EHBO secondary to pancreatitis in dogs, treated medically and surgically and to determine whether the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) differ between the treatment groups.

ANIMALS

41 dogs treated for EHBO secondary to pancreatitis during the period of May 2015 to November 2021.

METHODS

Records from 41 dogs diagnosed with EHBO secondary to pancreatitis were reviewed, and information extracted included clinical signs, ultrasound findings, NLR, PLR, histopathology, treatment, and outcomes.

RESULTS

18 of 19 (95%) surgical patients survived, while 12 of 21 (57%) medical patients survived. There was no difference in the length of hospitalization or time to return to adequate function between the groups; however, there was a significant difference in the 2- and 12-month survival between those treated surgically and medically. There was no difference in the NLR or PLR between surgically versus medically treated dogs or between survivors and nonsurvivors.

CLINICAL RELEVANCE

The mortality rate of surgery for EHBO secondary to pancreatitis may be lower than previously described, and in this cohort of dogs, those treated surgically had improved survival at 2 and 12 months compared to those treated medically.

Hypoplasia of Extrahepatic Biliary Tree and Intrahepatic Cholangiolopathy in Cystic Fibrosis Imperfectly Mimic Biliary Atresia in 4 Infants With Cystic Fibrosis and Kasai Portoenterostomy

Four male infants with cystic fibrosis and prolonged neonatal jaundice underwent Kasai procedure to relieve biliary obstruction due to apparent biliary atresia. The excised remnants had viscid mucus accumulation in hypoplastic gallbladders and distended peribiliary glands. Main hepatic ducts were narrow and/or malformed. Microscopic differences between the gallbladder and extrahepatic bile ducts in cystic fibrosis and sporadic biliary atresia were unequivocal, despite some histologic overlap; no erosive or fibro-obliterative lesions typical of biliary atresia were seen. Common in liver, biopsies were small duct cholangiopathy with intense focal cholangiolitis and massive accumulation of ceroid pigment within damaged cholangiocytes, and in portal macrophages, portal fibrosis, and unequivocal features of large duct obstruction were inconspicuous compared with biliary atresia. Plugs of bile in small ducts tended to be pale and strongly periodic acid-Schiff-reactive in cystic fibrosis. Distinguishing the liver lesion from that of biliary atresia is challenging but possible. Liver biopsies from 2 additional infants with cystic fibrosis and prolonged jaundice that spontaneously resolved showed a similar small duct cholangiopathy. Small gallbladders and extrahepatic ducts challenge surgical judgment as findings in liver biopsies challenge the pathologist. The decision to perform a Kasai procedure is reasonable when mimicry of biliary atresia is grossly complete. We hypothesize that a disorder of bile volume/flow during development and/or early infancy linked to the CFTR mutation alone or in combination with the stresses of neonatal intensive care causes destructive cholangiolitis and intrahepatic reduction of bile flow with secondary hypoplasia of extrahepatic biliary structures.

Percutaneous transhepatic cholecystostomy drainage in a dog with extrahepatic biliary obstruction secondary to pancreatitis

CASE DESCRIPTION

An 8-year-old 36.3-kg (79.9-lb) spayed female Rottweiler was evaluated because of anorexia and vomiting.

CLINICAL FINDINGS

Extrahepatic biliary obstruction (EHBO) secondary to pancreatitis was suspected on the basis of results from serum biochemical analyses, CT, and cytologic examination.

TREATMENT AND OUTCOME

Only marginal improvement was observed after 24 hours of traditional medical management; therefore, novel continual biliary drainage was achieved with ultrasonographically and fluoroscopically guided placement of a percutaneous transhepatic cholecystostomy drainage (PCD) catheter. Within 24 hours after PCD catheter placement, the dog was eating regularly, had increased intestinal peristaltic sounds on abdominal auscultation, no longer required nasogastric tube feeding, and had decreased serum total bilirubin concentration (7.7 mg/dL, compared with 23.1 mg/dL preoperatively). Bile recycling was performed by administering the drained bile back to the patient through a nasogastric tube. The PCD remained in place for 5 weeks and was successfully removed after follow-up cholangiography confirmed bile duct patency.

CLINICAL RELEVANCE

Transhepatic PCD catheter placement provided fast resolution of EHBO secondary to pancreatitis in the dog of the present report. We believe that this minimally invasive, interventional procedure has the potential to decrease morbidity and death in select patients, compared with traditional surgical options, and that additional research is warranted regarding clinical use, safety, and long-term results of this procedure in veterinary patients, particularly those that have transient causes of EHBO, are too unstable to undergo more invasive biliary diversion techniques, or have biliary diseases that could benefit from palliation alone.

Suspended over length biliary stents versus conventional plastic biliary stents for the treatment of biliary stricture: A retrospective single-center study

To compare patency between suspended over length biliary stents (SOBSs; made from nasobiliary tube) and conventional plastic biliary stents (CPBSs).We retrospectively analyzed 61 patients with extrahepatic biliary stricture who underwent SOBS placement (intrahepatic bile duct) and 74 patients who underwent CPBS placement. Stent patency and complications were compared.The SOBS group was slightly older and contained more females than the CPBS group but other baseline characteristics were similar. Malignant biliary obstruction accounted for 57.4% (SOBS group) and 45.9% (CPBS group) of cases. Technical success rate, hospital stay and post-procedure complications were similar between groups. Median patency in the CPBS and SOBS group was 116 (2-360) days and 175 (3-480) days, respectively (P <.001). The SOBS group had lower stent occlusion rates than the CPBS group at 3 months (9.8% vs 36.5%), 4 months (22.0% vs 55.4%), 5 months (35.6% vs 67.6%), and 6 months (39.3% vs 77.0%) (all P <.01). In Cox regression analysis, stent type (SOBS vs CPBS) was the only factor associated with patency (hazard ratio [HR]: 3.449; 95% CI: 1.973-6.028; P <.001).SOBS may have better medium-term patency than CPBS for benign/malignant biliary stricture.

Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study

BACKGROUND AND AIMS

ERCP-guided biliary drainage (ERCP-BD) is a criterion standard treatment for malignant biliary obstruction when curative surgery is not an option. Alternative methods such as percutaneous transhepatic biliary drainage would significantly lower the quality of life. EUS-guided biliary drainage (EUS-BD) has been developed and performed by experienced endoscopists. Therefore, the aims of this study were to evaluate the efficacy and safety of EUS-BD compared with ERCP in malignant biliary obstruction.

METHODS

The prospective randomized controlled study was conducted, and 30 patients were enrolled: 15 for each EUS-BD and ERCP-BD arms. The technical success, procedural time, clinical success, and adverse events were evaluated.

RESULTS

Thirty patients had extrahepatic malignant biliary tract obstruction (19 men, 11 women). Twenty-seven patients had unresectable pancreatic ductal adenocarcinomas, 1 patient had distal common bile duct cancer, and 2 patients had metastatic malignant lymphadenopathy. There were no significant differences both in terms of technical success rate and clinical success rate (100% vs 93% and 93% vs 100% in ERCP-BD vs EUS-BD, respectively; P = 1.00, P = 1.00). Four patients (31%) had tumor ingrowth-caused stent dysfunction in the ERCP-BD group, whereas 2 patients had food impaction and 2 patients had stent migration in the EUS-BD group. No significant procedure-related adverse events occurred in either group.

CONCLUSIONS

This prospective randomized controlled study suggests that EUS-BD has similar safety to ERCP-BD. EUS-BD was not superior to ERCP-BD in terms of relief of malignant biliary obstruction. EUS-BD may have fewer cases of tumor ingrowth but may also have more cases of food impaction or stent migration. (Clinical trial registration number: NCT01421836.).

Percutaneous stenting in malignant biliary obstruction caused by metastatic disease: clinical outcome and prediction of survival according to tumor type and further therapeutic options

BACKGROUND AND STUDY AIMS

Obstructive jaundice caused by metastatic disease leads to deterioration of general condition and short survival time. Successful decompression can offer symptom control and enable further treatment with chemotherapy, which can improve survival.

PATIENTS AND METHODS

Ninety-nine percutaneous transhepatic cholangiography (PTC) procedures with metallic stent placement were performed in 93 patients between 2007 and 2013. Files were retrospectively studied and a review of patients' demographics, clinical and laboratory parameters, treatment and survival was performed. Kaplan-Meier survival analysis with log-rank test was done in function of bilirubin level, tumor type and treatment with chemotherapy.

RESULTS

Hyperbilirubinemia resolved in 73% of procedures. Median survival time after the procedure was 48 (95%CI 34.8 - 61.1) days. If additional chemotherapy was possible, a median survival of 170 (95%CI 88.5 - 251.4) days was noted versus 32 (95%CI 22.4 - 41.5) days without chemotherapy (p < 0.01). Survival rates greatly differed between primary tumor type, with the largest benefit of PTC in colorectal cancer. In 35 % of the procedures minor or more severe complications were noted. The 30-day mortality was 33%, with 3 procedure related deaths.

CONCLUSION

PTC with metallic stenting can bring symptom relief and enable further treatment with chemotherapy, which can lead to a longer survival time, especially in colorectal cancer. However, in patients in whom palliative stenting failed to resolve the hyperbilirubinemia survival is short.

[PRINCIPLES OF THE HEPATICO-JEJUNOANASTOMOSIS FORMATION, USING METHOD OF THE SOFT-TISSUES HF-ELECTRIC WELDING IN CLINICAL PRACTICE]

Hepatico-jejunoanastomosis (HJA) was formed in accordance to the high-frequency electric welding method: in 14 patients – for the main bile outflow disorders, in 8 of them – as a consequence of the periampullar zone malignances, in 6 – stricture of a common hepatic duct, HJA earlier formatted, purulent cholangitis, iatrogenic damage of biliary ducts. In all the patients the welded averting one-layered termino-lateral or latero-lateral HJA were formatted. The welded anastomoses have appeared hermetic, sufficiently hard, immediately after the formation and further.

Comparison of the efficacy of covered versus uncovered metallic stents in treating inoperable malignant common bile duct obstruction: a randomized trial

PURPOSE

To compare patency and overall survival achieved with covered versus uncovered metallic stents among patients with inoperable malignant extrahepatic biliary obstruction.

MATERIALS AND METHODS

There were 40 patients enrolled in this prospective randomized study between January 2012 and July 2013. Mean age of patients was 62.6 years (range, 43-86 y). The malignancies causing extrahepatic biliary obstruction were pancreatic cancer (n = 18), stomach cancer (n = 13), gallbladder cancer (n = 3), common bile duct cancer (n = 2), and other cancer types (n = 4). Uncovered (n = 20) and covered (n = 20) stents were used. Stent patency, overall survival, and complications were evaluated and statistically compared.

RESULTS

Mean patency of uncovered stents (413.3 d ± 63.0) was significantly longer than mean patency of covered ones (207.5 d ± 46.0; P = .041). Mean overall survival was 359.9 days ± 61.5 for uncovered stents, which was statistically similar to survival of 350.5 days ± 43.8 for covered stents (P = .271). Causes of recurrent obstruction included tumor ingrowth (n = 2), tumor overgrowth (n = 5), debris or food material (n = 5), and stent migration (n = 2). One case of acute cholecystitis occurred in covered stent group.

CONCLUSIONS

Uncovered metallic stents had superior patency duration than covered stents for patients with malignant extrahepatic biliary obstruction. However, the overall complication and survival rates achieved with covered and uncovered stents were similar.

Removal of an embedded "covered" biliary stent by the "stent-in-stent" technique

A 46-year-old man was admitted with obstructive jaundice and cross-sectional imaging with computed tomography suggested distal biliary obstruction. A distal common bile duct stricture was found at endoscopic retrograde cholangiopancreatography (ERCP) and cytology was benign. A 6 cm fully covered self-expanding metal stent (SEMS) was inserted across the stricture to optimize biliary drainage. However, the SEMS could not be removed at repeat ERCP a few months later. A further fully covered SEMS was inserted within the existing stent to enable extraction and both stents were retrieved successfully a few weeks later. Fully covered biliary (SEMS) are used to treat benign biliary strictures. This is the first reported case of inability to remove a fully-covered biliary SEMS. Possible reasons for this include tissue hyperplasia and consequent overgrowth into the stent proximally, or chemical or mechanical damage to the polymer covering of the stent. Application of the stent-in-stent technique allowed successful retrieval of the initial stent.

Single-balloon enteroscopy for treating Roux-en-Y choledochojejunostomy stenosis after liver transplantation: a case report

Endoscopic treatment of biliary tract complications after Roux-en-Y surgery is still a challenge. With balloon enteroscopy, we can reach previously inaccessible areas changing the management of biliopancreatic diseases in patients with surgically altered anatomy. We report a case of single-balloon enteroscopy plus endoscopic retrograde cholangiopancreatography for the treatment of a pinpoint stricture in a hepaticojejunal anastomosis after liver transplantation.

Hyaline vascular Castleman's disease involving the biliary tract

We report a case of Castleman's Disease (CD), hyaline vascular subtype involving the biliary tract with obstruction. A 43 year old man presented with a 5 week history of abdominal and back pain with biliary obstructive symptoms. He was jaundiced with persistently high LFTs. Radiological investigation revealed a stricture in the extrahepatic biliary tract. The clinical impression at the time was of sclerosing cholangitis with bile duct cholangiocarcinoma. A Whipple's procedure was performed. Histology and immunohistochemistry supported the histologic diagnosis of CD of hyaline vascular subtype. There was no evidence of disease elsewhere and the patient was disease free after a 6 year follow-up. Our case describes the hyaline vascular subtype of CD, a relatively rare disease occurring in a previously undescribed location.

Intraductal ultrasound substantiates diagnostics of bile duct strictures of uncertain etiology

AIM: To report the largest patient cohort study investigating the diagnostic yield of intraductal ultrasound (IDUS) in indeterminate strictures of the common bile duct.

METHODS: A patient cohort with bile duct strictures of unknown etiology was examined by IDUS. Sensitivity, specificity and accuracy rates of IDUS were calculated relating to the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery. Analysis of the endosonographic report allowed drawing conclusions with respect to the T and N staging in 147 patients. IDUS staging was compared to the postoperative histopathological staging data allowing calculation of sensitivity, specificity and accuracy rates for T and N stages. The endoscopic retrograde cholangio-pancreatography and IDUS procedures were performed under fluoroscopic guidance using a side-viewing duodenoscope (Olympus TJF 160, Olympus, Ltd., Tokyo, Japan). All procedures were performed under conscious sedation (propofol combined with pethidine) according to the German guidelines. For IDUS, a 6 F or 8 F ultrasound miniprobe was employed with a radial scanner of 15-20 MHz at the tip of the probe (Aloka Co., Tokyo, Japan).

RESULTS: A total of 397 patients (210 males, 187 females, mean age 61.43 ± 13 years) with indeterminate bile duct strictures were included. Two hundred and sixty-four patients were referred to the department of surgery for operative exploration, thus surgical histopathological correlation was available for those patients. Out of 264 patients, 174 had malignant disease proven by surgery, in 90 patients benign disease was found. In these patients decision for surgical exploration was made due to suspicion for malignant disease in multimodal diagnostics (computed tomography scan, endoscopic ultrasound or magnetic resonance imaging). Twenty benign bile duct strictures were misclassified by IDUS as malignant while 14 patients with malignant strictures were initially misdiagnosed by IDUS as benign resulting in sensitivity, specificity and accuracy rates of 93.2%, 89.5% and 91.4%, respectively. In the subgroup analysis of malignancy prediction, IDUS showed best performance in cholangiocellular carcinoma as underlying disease (sensitivity rate, 97.6%) followed by pancreatic carcinoma (93.8%), gallbladder cancer (88.9%) and ampullary cancer (80.8%). A total of 133 patients were not surgically explored. 32 patients had palliative therapy due to extended tumor disease in IDUS and other imaging modalities. Ninety-five patients had benign diagnosis by IDUS, forceps biopsy and radiographic imaging and were followed by a surveillance protocol with a follow-up of at least 12 mo; the mean follow-up was 39.7 mo. Tumor localization within the common bile duct did not have a significant influence on prediction of malignancy by IDUS. The accuracy rate for discriminating early T stage tumors (T1) was 84% while for T2 and T3 malignancies the accuracy rates were 73% and 71%, respectively. Relating to N0 and N1 staging, IDUS procedure achieved accuracy rates of 69% for N0 and N1, respectively. Limitations: Pre-test likelihood of 52% may not rule out bias and over-interpretation due to the clinical scenario or other prior performed imaging tests.

CONCLUSION: IDUS shows good results for accurate diagnostics of bile duct strictures of uncertain etiology thus allowing for adequate further clinical management.

[Laparoscopic choledochoduodenostomy]

The article presents the results of laparoscopic choledoch-duodenostomy (CDS) applied to 23 patients with benign strictures of distal part of common bile duct (CBD). 21 patients had cholelithiasis in combination with the CBD stricture. The rest 2 patients had acalculous postcholecystectomy stricture. The laparoscopic CDS was executed by 5 trocars: 4 were placed in standard cholecystectomy positions and the 5th was placed by the right pararectal line at the umbilicus level and was used for traction of duodenum and continuous aspiration. 2 sm long side-to-side CDS was performed with interrupted sutures. The mean operative time was 128±36 (90-205) min. There was no conversion. The mean hospital stay was 4.5 (3-9) days. There was no mortality. 2 patients developed an anastomosis bile leakage: one received the relaparoscopy and T-draining of the CDS, in another patient the leakage seased spontaneously. 82.7% of patients showed excellent and good long term results. 3 patients reported bad outcome and very bad result was registered in 1 patient. In conclusion, the laparoscopic CDS gives good outcomes in experienced hands and could be considered as an alternative to endoscopic sphincterotomy in patients with distal CBD stenosis.

Periampullary carcinoma: better prognosis with early pre-stenting referral to surgery

This study was undertaken to find out reasons of delayed referral for surgical treatment and to assess the effect of delayed referral on management and prognosis of patients with periampullary carcinoma. Patients with histopathologically proved periampullary carcinoma (n=41) during the period January 2010 to December 2010 who had been admitted into the department of surgery, Bangabandhu Sheikh Mujib Medical University, Shahbagh, Dhaka, Bangladesh (BSMMU) were included in this study. Information of the patient was retrieved from medical records. Patients and relatives were interviewed for reasons of delay in seeking surgical help. Patients were divided into two groups: Group I: those who admitted to surgical unit within one month (6 days to 1 month) of noticing jaundice (n=13), and Group II: those who admitted to surgical unit after one month (1.2 months to 18 months) of noticing jaundice (n=28). Parameters were compared between two groups. Patients in group II were poor liver function and nutritional status needed more supplementary therapy in perioperative period. The incidence of distant metastasis and ascites were more frequent in Group II than Group I patients. Definitive procedure (Whipple's operation) was possible in 53.8% patients in Group I whereas only 7.1% in Group II patients (p <0.05). The reasons for delay referral to surgery were due to patient's ignorance, superstition and fear of receiving operative treatment. Delay in diagnosis of periampullary carcinoma as a cause of jaundice and immediate relief of jaundice with ERCP and stenting is another important cause of delay in seeking definitive operative treatment. Awareness of public as well as general physicians is required for early referral of patients with periampullary carcinoma to surgery. Joint assessment of these patients by Gastroenterologist and Hepatobiliary surgeons before internal biliary drainage will improve prognosis.

[A rare tumor-like lesion of the pancreatic head with bile duct obstruction]

Tumors of the pancreatic head commonly consist of carcinomas whereas other entities are rare exceptions. Extrapulmonary sarcoidosis is well-known but is extremely rare when detected as a mass in the pancreatic head. In general the diagnosis of sarcoidosis requires histologic examination with verification of non-caseous, epithelioid cell-like granulomas. Systemic therapy consists of steroids when the patient exhibits symptoms or in the case of progression of the disease. However, in some cases extended abdominal resections are also required to confirm the diagnosis and/or to treat symptoms.

One-step placement of a fully-covered metal stent in endosonography-guided biliary drainage for malignant biliary obstruction

BACKGROUND

Although reports on endosonography-guided biliary drainage (ESBD) have been increasing, only a few discuss deployment of a self-expandable metal stent (SEMS) in the first session.

OBJECTIVE

To evaluate the safety and efficacy of ESBD with the one-step placement of a newly designed fully-covered SEMS.

PATIENT AND METHODS

Five patients with malignant biliary obstruction in whom one-step placement of an anti-migration designed SEMS in the first session of ESBD had been attempted between January 2007 and October 2009 were included in this study. Main outcome measurements were technical and clinical successes, early complications, and short-term results.

RESULTS

ESBD was attempted to bridge the extrahepatic bile duct and the duodenum and one-step SEMS placement was successful in all cases. There were no early complications related to ESBD and excellent biliary decompression was obtained in all cases. SEMS dysfunction such as stent migration and occlusion was not seen during the follow-up period (mean follow-up 138 days, range 102-184 days).

CONCLUSION

One-step placement of a fully-covered SEMS in ESBD is possibly a safe and effective treatment for biliary obstruction.

[Endoscopic treatment of postcholecystectomy biliary strictures]

INTRODUCTION

Biliary strictures are a serious complication of biliary surgery. Historically, surgery was the treatment of choice. Then appeared the endoscopic treatment with results comparable with those achieved by the surgery.

MATERIAL AND METHODS

Twenty-two patients underwent endoscopic treatment for postcholecystectomy benign biliary stricture between 1990 and 2006. After pneumatic dilation with ballons, stents were inserted. Stents were exchanged between 3 and 8 months and ultimately removed from all patients at 12 months.

RESULTS

Endoscopic treatment was successful in 16 cases (72%): in 14 was excellent (63%), in 2 good (10%) and in 6 bad (27%). These cases required surgery. Early complications were cholangitis in 2 cases and pancreatitis in 3; late complications developed in 3 cases, with 2 o more cholangitis episodes. There was no mortality.

CONCLUSIONS

Endoscopic treatment of biliary strictures with dilation and stent insertion was successful in 72% of the 22 cases in our series, with low morbility and no mortality.

Endoscopic retrograde cholangiopancreaticography prior to explorative laparotomy avoids unnecessary surgery in patients suspected for biliary atresia

BACKGROUND/AIMS

Timely diagnosis of biliary atresia (BA) requires key investigations that are less invasive but as accurate as possible. Non-invasive imaging preselects patients before explorative laparotomy is performed. The purpose of this prospective study was to evaluate the accuracy of endoscopic retrograde cholangiopancreaticography (ERCP) in these patients and to discuss its relevance to future diagnostic guidelines in neonatal jaundice.

METHODS

Over a 7-year period, ERCP was routinely performed in cholestatic patients less than 6 months of age suspected for an extrahepatic origin of cholestasis, most likely BA. Endoscopic diagnosis was correlated with intraoperative findings.

RESULTS

In 140 consecutive patients (mean age: 60 days; weight: 4 kg), ERCP excluded BA in 34 (25%) but failed in 18 newborns (13%) for technical reasons. The average procedure time was 23 min, and no severe complications occurred. Explorative laparotomy was performed in 106 patients and revealed BA in 80 cases. In this series, the sensitivity of ERCP for diagnosing biliary atresia was 92% and specificity was 73%.

CONCLUSIONS

In preselected patients, ERCP is not an alternative to non-invasive imaging, but it avoids unnecessary surgical procedures in almost 25% of the cases. Hence, ERCP is recommended prior to explorative laparotomy in all patients suspected for BA.

A case of Mirizzi's syndrome mimicking carcinoma: the role of CBD-stenting for easy surgical management

Mirizzi's syndrome accounts for an important risk for bile tree injury during surgery, since preoperative diagnosis is missed in half of the cases and is often difficult to differentiate from carcinoma. A 79-year-old male, with a known history of cholelithiasis, was admitted with a progressive obstructive jaundice over 20 days, without pain, fever, or other symptoms. Magnetic resonance cholangiopancreatography described possible microlithiasis of the distal bile duct, but on endoscopic retrograde cholangiopancreatography (ERCP), an irregular stenosis was detected under the junction of hepatic ducts, which was described as possibly neoplastic. A temporary stent was placed and the patient was referred for surgery. On first view the gallbladder appeared hard, embedded in adhesions, giving the impression of an unresectable tumor and the bile duct was not approachable. After a fundus-down incision of the gallbladder multiple stones were extracted. Frozen biopsies from the gallbladder wall were negative. The incision was extended towards the gallbladder neck and a large communication with the common bile duct (CBD) was revealed. A difficult partial cholecystectomy was performed, followed by cholecystojejunostomy with a Roux-en-Y jejunal loop. The patient had a totally uneventful postoperative course. Stent removal was succeeded endoscopically 1 month later. The importance of preoperative ERCP and CBD stenting is highlighted in this article. ERCP may have failed to distinguish Mirizzi's syndrome from carcinoma, however the stent placement saved the cardiologically compromised patient from further surgical manipulations. Therefore, in ambiguous cases, whatever the final diagnosis turns to be, either carcinoma or Mirizzi's syndrome, CBD stenting can be useful for the final management of the patient.

Preoperative biliary drainage in patients with obstructive jaundice: history and current status

RATIONALE

Preoperative biliary drainage (PBD) has been introduced to improve outcome after surgery in patients suffering from obstructive jaundice due to a potentially resectable proximal or distal bile duct/pancreatic head lesion. In experimental models, PBD is almost exclusively associated with beneficial results: improved liver function and nutritional status; reduction of systemic endotoxemia; cytokine release; and, as a result, an improved immune response. Mortality was significantly reduced in these animal models. Human studies show conflicting results.

FINDINGS

For distal obstruction, currently the "best-evidence" available clearly shows that routine PBD does not yield the appreciated improvement in postoperative morbidity and mortality in patients undergoing resection. Moreover, PBD harbors its own complications. However, most of the available data are outdated or suffer from methodological deficits.

CONCLUSION

The highest level of evidence for PBD to be performed in proximal obstruction, as well as over the preferred mode, is lacking but, nevertheless, assimilated in the treatment algorithm for many centers. Logistics and waiting lists, although sometimes inevitable, could be factors that might influence the decision to opt for PBD, as well as an extended diagnostic workup with laparoscopy (on indication) or scheduled preoperative chemotherapy.

[Alternative endobiliary operations for choledocholithiasis and papilla of Vater stenosis]

The immediate results of endoscopic papillosphincterotomy (EPST) (n=754) and endobiliary balloon dilatation (n=120) were comparatively analyzed. Survey included patients with choledocholithiasis and papilla Vateri stenosis. The use of balloon dilatation and EPST was defined by the size and amount of gallstones. Balloon dilatation was preferable when there less then 3 concrements. "Critical" diameter of the gallstone, which permitted the use of endobiliary dilatation, was 9 mm. In cases of the papilla Vateri stenosis balloon dilatation also demonstrated better results then EPST: 93,5+/-3,6% and 79,4+/-2,8% of satisfactory results, respectively).

[Results of surgical treatment of patients with subhepatic cholestasis of non-tumor etiology]

There were studied the results, termed from 12 to 24 months, of operatively treated patients for subhepatic cholestasis of nontumoral etiology. The general clinical examination, ultrasonographic investigation were performed to the patients, as well as morphological changes estimation in hepatic fine-needle biopsies samples, biochemical indices and the state of systemic hepatic blood circulation. Application of complex staged operative interventions, added by hepatoregenerative operations, have had favored normalization of laboratory indices and structural hepatic changes as well as the hepatic blood supply improvement due to systolic inflow enhancement by 26% and microcirculatory bed blood circulation -- by 51%.

The Mirizzi syndrome: multidisciplinary management promotes optimal outcomes

The Mirizzi syndrome (MS) is a rare cause of obstructive jaundice produced by the impaction of a gallstone either in the cystic duct or in the gallbladder, resulting in stenosis of the extrahepatic bile duct and, in severe cases, direct cholecystocholedochal fistula formation. Sixteen patients were treated for MS in our center over the 12-year period 1993--2005 for a prevalence of 0.35% of all cholecystectomies performed. One patient was diagnosed only at the time of cholecystectomy. The other 15 patients presented with laboratory and imaging findings consistent with choledocholithiasis and underwent preoperative endoscopic retrograde cholangiopancreatography, which established the diagnosis in all but one patient. All patients underwent cholecystectomy. An initial laparoscopic approach was attempted in 14 patients, of whom 11 were converted to open procedures. MS was recognized operatively in 15 patients with definitive stone extraction and relief of obstruction in 13 patients. T-tubes were placed in 10 patients and 1 patient required a choledochoduodenostomy. Two patients required postoperative laser lithotripsy via a T-tube tract to clear their stones; and in another patient, MS was detected and treated via postoperative endoscopic retrograde cholangiopancreatography (ERCP). MS remains a serious diagnostic and therapeutic challenge for endoscopists and biliary surgeons.

Late morbidity after duodenum-preserving pancreatic head resection with bile duct reinsertion into the resection cavity

BACKGROUND

Reinsertion of the distal common bile duct (CBD) into the pancreatic resection cavity during duodenum-preserving pancreatic head excision (DPPHE) may be an alternative option to Whipple resection or bilioenteric anastomosis when chronic pancreatitis is associated with CBD stenosis.

METHODS

Outcome in 82 patients with chronic pancreatitis who underwent DPPHE with CBD reinsertion was compared with that in 432 who had DPPHE without reinsertion and 50 who had a Whipple procedure or pylorus-preserving pancreatoduodenectomy (PPPD).

RESULTS

There were no deaths after DPPHE with CBD reinsertion, compared with four (0.9 per cent) after DPPHE without reinsertion and three (6 per cent) after classical resection. Overall morbidity rates were 30, 28.9 and 36 per cent respectively. Fifteen patients (18 per cent) who had DPPHE with CBD reinsertion developed a stricture at the reinsertion site, compared with a long-term stricture rate of 2.3 per cent (ten patients) after DPPHE without CBD reinsertion and 4 per cent (two patients) after PPPD/Whipple resection.

CONCLUSION

Although associated with a high incidence of anastomotic stricture, reinsertion of the CBD into the resection cavity as part of DPPHE can be used to preserve duodenal passage and offers an alternative to extended resection for chronic pancreatitis.

Endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures

Several conditions may cause benign biliary stricture formation. Intraoperative bile duct injury, most often sustained during laparoscopic cholecystectomy, is the leading cause. Although surgical bypass procedure was the traditional treatment of choice for benign extrahepatic biliary strictures, therapeutic endoscopic retrograde cholangiopancreatography has recently come into favor; however, success rates have been variable and largely dependent on the underlying etiology. Because endoscopic therapy may be unsuccessful, a multidisciplinary approach to management, with surgical or radiological intervention if necessary, should be considered.

Evaluation of hepatobiliary excretion and enterobiliary reflux in rats with biliary obstruction submitted to bilioduodenal or biliojejunal anastomosis

Bilioduodenal and biliojejunal anastomoses are effective for the treatment of biliary obstruction. The objective of this study was to compare the effects of these anastomoses on hepatobiliary excretion and enterobiliary reflux. Enterobiliary reflux and biliary excretion were evaluated respectively after oral administration of technetium ((99m)Tc) in combination with sodium phytate and intravenous infusion of (99m)Tc with diisopropyl-iminodiacetic acid. Enterobiliary reflux occurred to an equal degree in the bilioduodenal and biliojejunal groups. Maximum hepatic activity time (T(max)) and radiotracer clearance half-time (T(1/2)) were similar in both groups. However, when compared with that found for the sham-operated group, T(max), and T(1/2) were higher in the biliojejunal group (P = 0.02 and P = 0.01, respectively). Histopathological analysis showed marked reduction in ductal proliferation in both groups. These data undermine the theoretical advantages attributed to biliojejunal anastomosis and further the understanding of the pathophysiology of cholangitis that occurs even with patent anastomosis.

[Possibilities of radical surgical treatment of patients with tumoral obstruction of extrahepatic biliary ducts]

Experience of radical surgical treatment of 32 patients, suffering extrahepatic biliary ducts (EBD) tumor, was analyzed. The respectability index of a Clatskin tumor have constituted 12.5%, and of the EBD middle portion--25%. In 8 patients an open operative intervention was performed and in 1--laparoscopic procedure was applied. The respectability index of a distal EBD tumors have constituted 29.6%. Postoperative lethality was 15.6%.

Treatment of pancreatitis-associated extrahepatic biliary tract obstruction by choledochal stenting in seven cats

OBJECTIVES

To report the clinicopathological findings and outcome in cats with pancreatitis-associated extrahepatic biliary tract obstruction (EHBO) treated by choledochal tube stenting.

METHODS

Medical records of cats with EHBO secondary to pancreatitis that underwent choledochal stenting were reviewed. Information on outcome was obtained by re-examination of the cat or by telephone interview with the owners.

RESULTS

All cats had pancreatitis confirmed by histopathological examination of biopsy samples (n=6) or suspected based on gross examination at surgery (n=1). In six cats, a section of 3.5 to five French gauge red rubber catheter and in one cat a section of 22 G intravenous catheter were used as a choledochal stent. Two cats developed re-obstruction of the biliary tract within a week of the original surgery. One cat had confirmed episodes of ascending cholangitis postoperatively. Two cats had chronic intermittent vomiting in the postoperative period. Two cats died during the perioperative period. Five cats survived to discharge, three of which died seven to 24 months postoperatively and two of which remain alive to date.

CLINICAL SIGNIFICANCE

Choledochal stenting is an alternative to biliary diversion for management of feline pancreatitis-associated EHBO in select cases. However, there may be greater morbidity with this technique in cats compared with dogs.

Unusual causes of extrahepatic biliary obstruction in children: a case series with review of literature

This paper highlights the etiology, diagnosis, management and outcome in nine unusual cases of extrahepatic biliary obstruction in children. Extrahepatic biliary atresia and choledochal cyst constituted 127 out of 136 (93%) cases of all pediatric surgical biliary disorders managed between March 2000 and February 2007 at the reporting centre. However, nine children (aged 1.5-15 years) presented with uncommon causes like (1) idiopathic benign non-traumatic inflammatory stricture (n = 3), (2) idiopathic fibrosing chronic pancreatitis (n = 2), (3) post-cholecystectomy type 4 benign biliary stricture (n = 1), (4) post-acute pancreatitis pseudo-cyst of pancreas (n = 1), (5) non-Hodgkin's lymphoma (NHL) with extramural common bile duct compression and gall bladder perforation (n = 1), and (6) Langerhan cell histiocytosis (LCH, n = 1). The clinical features and the diagnostic work up of each group are discussed. A preoperative endoscopic/percutaneous biliary drainage was required in four children because of cholangitis at presentation. A biliary-enteric anastomosis was performed for all seven children in groups (1)-(4). The patients with NHL and LCH were referred for chemotherapy after establishing tissue diagnosis at laparotomy. With a follow-up period of 3 months to 7 years, seven children (with the exception of patients with NHL and LCH) are currently anicteric. This paper draws attention to some infrequently discussed causes of extrahepatic biliary obstruction in children. The management entails a carefully planned combination of endoscopic interventions, interventional radiology and surgery. The outcome in benign cases is usually satisfactory.

[Diagnostics and surgical tactics for Mirizzi syndrome]

Analysis of clinical investigation and surgical treatment of 284 patients with Mirizzi syndrome (MS) was carried out. According to A.Csendes and co-authors classification (1989) 223 patients had the I type of MS, 49 patients--the II type, 9 patients--the III type, 3 patients--the IV type. Diagnosis was ascertained before the operation in 27.4% of patients; with the help of ultrasound study--in 9.1%, by means of retrograde cholangiopancreatography--in 18.3%. In other cases diagnosis was determined during the operation. Mode of the operation depended on the type of MS. Perioperative duct damage was signed in 4 cases (1.4%). Laparoscopic cholecystectomy (LCE) was carried out to 56 patients; cholecystectomy from mini-access--to 41 patients. Remaining 187 patients underwent abdominal operation. In 2 cases operation was finished by external duct drainage; in 7 Roo choledochojejunostoma was formed. Authors suggest that the I type of MS is not a contra-indication for LCE. In case of difficulties in LCE switch to cholecystectomy from mini-access is preferable.

Unusual segmental stricture of the lower common bile duct mimicking bile duct cancer

In some cases of bile duct stricture, malignancy cannot be diagnosed preoperatively even with the use of various diagnostic imaging modalities and histologic examination. As long as malignancy cannot be ruled out completely, surgery can be undertaken for the purposes of diagnosis and treatment. We report a case of unusual segmental stricture of the lower common bile duct mimicking bile duct cancer and discuss the differential diagnosis.

[Application of exchangeable transhepatic frame stents in patients with posttraumatic strictures of the hepatic and common bile duct]

For the period from 2000 through 2007 there were 27 patients treated for lesions of extrahepatic bile ducts of different genesis. Since all the lesions were high, we have formed biliodigestive anastomoses on the exchangeable transhepatic drains by the method of Groetz-Saypol-Kurian. In a month after the operation and a standard management of the exchangeable transhepatic drains we departed from the classical technique and applied nonperforated drains. Using the nonperforated exchangeable transhepatic drains in patients after reconstructive operations on the extrahepatioc bile ducts gave good immediate results of operations and substantially improved quality of life of the patients in the postoperative period.

Minimally Invasive Cholecystostomy in the Dog: Evaluation of Placement Techniques and Use in Extrahepatic Biliary Obstruction

OBJECTIVE

To evaluate 4 methods of cholecystostomy catheter placement and to report on laparoscopic (Lap) cholecystostomy for the management of extrahepatic biliary obstruction (EHBO) in 3 dogs.

STUDY DESIGN

Experimental study and clinical report.

ANIMALS

Cadaveric dogs (n=20); 2 canine and 1 feline patient.

METHODS

Pigtail cholecystostomy catheters were inserted in 20 canine cadavers using ultrasound (US) or Lap guidance. Insertion routes were either transperitoneal or transhepatic. Methods studied included Lap-transperitoneal, US-transperitoneal, US-transhepatic, and US-Seldinger (n=5 dogs/group). Insertion success, pleural penetration, and insertion site leakage (Lap-transperitoneal group) were evaluated. Three clinical EHBO cases were treated by Lap-transperitoneal technique.

RESULTS

Insertion success was 100% by Lap-transperitoneal but 0% with US-transperitoneal and US-Seldinger methods. US-transhepatic yielded 3 of 5 successful placements. The pleura was penetrated in all US-transhepatic and US-Seldinger insertions. Leakage pressure for Lap-transperitoneal catheters averaged 75 cm H2O (+/-20 cm H2O). Lap-transperitoneal cholecystostomy resulted in marked improvement in 2 dogs, but the catheter became obstructed in the cat. One dog spontaneously regained common bile duct patency and the remaining 2 animals had successful cholecystoenterostomy.

CONCLUSIONS

In cadaver testing, the Lap-transperitoneal cholecystostomy method was superior based on high insertion success with no pleural penetration. In 2 clinical cases, Lap-transperitoneal placement successfully provided biliary drainage for patient stabilization.

CLINICAL RELEVANCE

The role for temporary cholecystostomy has yet to be established, but may aid patient stabilization and mortality reduction in EHBO.

Cap-assisted ERCP in patients with a Billroth II gastrectomy

BACKGROUND

ERCP is difficult in patients with a Billroth II gastrectomy because of anatomical changes.

OBJECTIVE

Cap-assisted ERCP can improve the cannulation rate and the success rate of stone removal.

DESIGN

Case series.

SETTING

A tertiary referral center.

PATIENTS AND INTERVENTIONS

Ten consecutive patients with bile-duct stones (9) or a distal common bile duct stricture (1), who had previously undergone Billroth II gastrectomy and were referred for ERCP, were analyzed for the outcome of their ERCP. All procedures were carried out with a cap-fitted regular forward-viewing endoscope.

MAIN OUTCOME MEASUREMENTS

Ability to perform afferent loop intubation and bile-duct cannulation.

RESULTS

Of 10 patients in whom ERCP was attempted, afferent loop intubation and selective bile-duct cannulation were achieved in all patients (100%). Endoscopic sphincterotomy (EST) was successful in all 10 patients (100%). All stones were removed by EST alone in 7 patients and by both EST and endoscopic papillary balloon dilation in 2 patients. There were no serious complications in the patients.

LIMITATIONS

Small sample size, single-center experience.

CONCLUSIONS

Diagnostic and therapeutic ERCP with a cap-fitted regular forward-viewing endoscope was successful in all patients with a prior Billroth II gastrectomy. The high rate of successful ERCP was achieved by improving afferent loop intubation and bile-duct cannulation with a cap-fitted endoscope.

Initial and long-term outcome after palliative surgical drainage of 269 patients with malignant biliary obstruction

AIMS

This study aimed to analyse the current outcome after palliative surgical drainage of malignant biliary obstruction.

METHOD

From 1992 to 2003, perioperative parameters and the incidence and indications of readmissions were analysed in 269 patients who underwent a palliative biliary bypass for periampullary carcinoma.

RESULTS

Hospital mortality occurred in seven patients and median postoperative stay was 10 days. Anastomotic leakage occurred in three patients and intraabdominal haemorrhage in eight patients. Overall 75 patients experienced a complication. Nine patients underwent a relaparotomy during initial hospital admission. Overall, 142 patients were readmitted, 13 for indications related to the biliary bypass, 11 for surgery-related indications. Twenty-five patients were readmitted for radiochemotherapy, 112 for progressive disease and 23 for indications not related to the disease. Median survival was 7.5 months and the 3-year survival 3%. Survival was significantly lower in patients with metastases and in those who underwent elective bypass for gastric outlet obstruction.

CONCLUSION

Current hospital mortality after palliative biliary bypass as well as readmission rates for complications related to the biliary bypass or surgical procedure are low. Surgical biliary bypass is a safe and effective palliative treatment for patients with malignant biliary obstruction.

Endoscopic retrograde cholangiopancreaticography with or without stenting in patients with pancreaticobiliary malignancy, prior to surgery

BACKGROUND

Postoperative morbidity and mortality are high in patients undergoing pancreatico-duodenectomy for malignant pancreatico-biliary stricture. Different approaches have been tried to improve the outcomes, including pre-surgical biliary stenting with endoscopic retrograde cholangiopancreaticography (ERCP).

OBJECTIVES

To assess the beneficial and harmful effects of biliary stenting via ERCP for pancreatico-biliary stricture confirmed or suspected to be malignant, prior to surgery.

SEARCH STRATEGY

We identified trials through The Cochrane Hepato-Biliary Group Controlled Trials Register (October 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2006), MEDLINE (1950 to October 2006), EMBASE (1980 to October 2006), and Science Citation Index Expanded (1945 to October 2006). We also searched the references in the published papers and wrote to stent producers.

SELECTION CRITERIA

Randomised trials comparing ERCP with biliary stenting versus ERCP without biliary stenting for pancreatico-biliary malignancy prior to surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion and extracted data. The primary pre-surgical, post-surgical, and final outcome measures were mortality. The secondary outcomes were complications such as cholangitis, pancreatitis, bleeding, pancreatic fistula, intra-abdominal abscess, improvement in bilirubin, and quality of life. Dichotomous outcomes were reported as odds ratio (OR) with 95% confidence interval (CI) based on fixed- and random-effect models.

MAIN RESULTS

We identified two randomised trials with 125 patients undergoing pancreatico-duodenectomy; 62 patients underwent ERCP with biliary stenting and 63 had ERCP without biliary stenting prior to surgery. Pre-surgical mortality was not significantly affected by stenting (OR 3.14, 95% CI 0.12 to 79.26), while there were significantly more complications in the stented group (OR 43.75, 95% CI 2.51 to 761.8). Stenting had no significant effect on the post-surgical mortality (OR 0.75, 95% CI 0.25 to 2.24). However, post-surgical complications were significantly less in the stented group (OR 0.45, 95% CI 0.22 to 0.91). Overall mortality (OR 0.81, 95% CI 0.17 to 3.89) and complications (OR 0.50, 95% CI 0.01 to 23.68) were not significantly different in the two groups.

AUTHORS' CONCLUSIONS

We could not find convincing evidence to support or refute endoscopic biliary stenting on the mortality in patients with pancreatico-biliary malignancy. Large randomised trials are needed to settle the question of pre-surgical biliary stenting.

Mirizzi syndrome in a patient with anomalous connection of the cystic duct into the right hepatic duct

In 1948, Mirizzi described a syndrome characterized as the obstruction of the common hepatic duct by a stone located in the gallbladder's neck or in the cystic duct. We present a rare case of Mirizzi syndrome resulting from a fistula involving the cystic duct, the neck of the gallbladder, and the right hepatic duct. This finding was possible because the patient had a rare biliary anatomic variation: the insertion of the cystic duct straight in the right hepatic duct. The diagnosis was suggested by abdominal ultrasonography and confirmed by endoscopic retrograde cholangiopancreatography. The surgical approach was performed by means of an open cholecystectomy, common biliary duct exploration using the right hepatic duct and a transduodenal papillotomy, and insertion of a long limb T-tube through the right hepatic duct to drain the common duct. The procedure was successful, and after an 18-month period, the patient is free of symptoms.

Double-barrel common bile duct: a rare cause of extrahepatic biliary obstruction

Double-barrel common bile duct is rare. We report a 50-year-old woman with defective canalization of the common bile duct, presenting with extrahepatic biliary obstruction due to stones in one compartment. CT scan highlighted this anomaly. After failed attempts at stone extraction at ERCP, she was successfully operated on.

Reoperation of biliary tract by laparoscopy: a consecutive series of 26 cases

BACKGROUND

In the past, previous operation of biliary tract represented a contraindication to perform reoperation by laparoscopy. As experience with laparoscopic techniques and instrumentation has expanded, reoperation of biliary tract with laparoscope has become an accepted procedure in the management of cholelithiasis. We present our interesting experience with regard to reoperation of biliary tract by laparoscopy.

MATERIAL AND METHODS

Laparoscopic operation of biliary tract was performed on 3,674 consecutive patients from April, 1992 till June, 2005. Among these patients, 26 had a previous open operation of biliary tract and their clinical data were retrospectively analyzed as follows: seven cases had complicated intrahepatic bile duct stones (restricted at hepatic duct of the first and second order). Diameter of common bile duct in patients with common duct stones was above 1.2 cm, the number of stones for each patient was more than 3 and all the biggest stones exceeded 1 cm. In the 26 patients, preoperatively, stenosis of bile duct and malignant tumour were excluded by both radiological examination and detection of serological tumour markers.

RESULTS

The mean operative time was 125 min (75-190 min). Reoperations of biliary tract by laparoscope were successfully accomplished in 25 patients. One patient was converted to open operation and the common duct stones were removed by right angle forceps through short incision. None of the patients developed any severe complication, all of them recovered and were successfully discharged. Three cases with retained calculuses were successfully cured by removing these through the sinus tract of T tube.

CONCLUSIONS

Laparoscopic procedure is minimally invasive, safe and feasible for laparoscopic experts in case of reoperation of biliary tract. It is also a first method for patients for whom endoscopic sphincterotomy is contraindicated.

Surgery in Fasciola hepatica Pancreatitis: Report of a Case and Review of Literature

Fasciola hepatica is a trematode rarely causing disease in humans. In symptomatic cases, while various pathologies such as damage to liver parenchyma, acute cholecystitis, and obstructive jaundice can be seen, the development of pancreatitis is rarely mentioned in the literature. The treatment of the disease is medical. In cases where no definite diagnosis can be made or in incidental cases where common bile duct exploration is being done, F. hepatica can be detected accidentally during operation. No consensus has yet been reached on the surgical procedure to be applied in this condition. We report on our case due to the rare occurrence of pancreatitis as a complication. In surgical cases, external drainage of the bile is both crucial in observing the response to the treatment, and also should be accepted as part of the treatment.